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General NPI Number Information
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NPI Number | 1972082121
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Entity Type | Organization
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Legal Business Name | SOULISTIC COUNSELING CORNER, LLC
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Dates
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Enumeration Date | 08/08/2018
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Last Update Date | 08/08/2018
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Provider Practice Location Address
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Address Line | 415 N RICHARD JACKSON BLVD STE 204
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City | PANAMA CITY BEACH
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State | FL
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Zip | 32407-3694
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Country | US
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Telephone | 850-628-1956
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Fax |
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Provider Business Mailing Address
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Address Line | 415 N RICHARD JACKSON BLVD STE 204
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City | PANAMA CITY BEACH
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State | FL
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Zip | 32407-3694
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Country | US
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Telephone | 850-628-1956
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Fax |
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Authorized Official
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Title or Position | COUNSELOR/OWNER
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Name | SHAE NICOLE LUSTER
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Credential | LMHC
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Telephone | 850-628-1956
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | MH13989
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License Number State | FL
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